Glasgow Coma Score example form

{
  "resourceType" : "Questionnaire",
  "id" : "gcs",
  "contained" : [{
    "resourceType" : "ValueSet",
    "id" : "motor",
    "identifier" : [{
      "system" : "http://loinc.org",
      "value" : "http://loinc.org/ValueSet/LL357-5"
    }],
    "name" : "GCS Motor Value Set",
    "status" : "active",
    "description" : "LOINC ANSWER LIST    (LL357-5)",
    "compose" : {
      "include" : [{
        "system" : "http://loinc.org",
        "concept" : [{
          "code" : "LA6562-8",
          "display" : "No motor response"
        },
        {
          "code" : "LA6563-6",
          "display" : "Extension to pain"
        },
        {
          "code" : "LA6564-4",
          "display" : "Flexion to pain"
        },
        {
          "code" : "LA6565-1",
          "display" : "Withdrawl from pain"
        },
        {
          "code" : "LA6566-9",
          "display" : "Localizing pain"
        },
        {
          "code" : "LA6567-7",
          "display" : "Obeys commands"
        }]
      }]
    }
  },
  {
    "resourceType" : "ValueSet",
    "id" : "verbal",
    "identifier" : [{
      "system" : "http://loinc.org",
      "value" : "http://loinc.org/ValueSet/LL356-7"
    }],
    "name" : "GCS Verbal Value Set",
    "status" : "active",
    "description" : "LOINC ANSWER LIST    (LL356-7)",
    "compose" : {
      "include" : [{
        "system" : "http://loinc.org",
        "concept" : [{
          "code" : "LA6557-8",
          "display" : "No verbal response (>2yrs); no vocal response (<=2yrs)"
        },
        {
          "code" : "LA6558-6",
          "display" : "Incomprehensible sounds"
        },
        {
          "code" : "LA6559-4",
          "display" : "Inappropriate words"
        },
        {
          "code" : "LA6560-2",
          "display" : "Confused"
        },
        {
          "code" : "LA6561-0",
          "display" : "Oriented"
        }]
      }]
    }
  },
  {
    "resourceType" : "ValueSet",
    "id" : "eye",
    "identifier" : [{
      "system" : "http://loinc.org",
      "value" : "http://loinc.org/ValueSet/LL355-9"
    }],
    "name" : "GCS Eye Value Set",
    "status" : "active",
    "description" : "LOINC ANSWER LIST    (LL355-9)",
    "compose" : {
      "include" : [{
        "system" : "http://loinc.org",
        "concept" : [{
          "code" : "LA6553-7",
          "display" : "No eye opening"
        },
        {
          "code" : "LA6554-5",
          "display" : "Eye opening to pain"
        },
        {
          "code" : "LA6555-2",
          "display" : "Eye opening to verbal command"
        },
        {
          "code" : "LA6556-0",
          "display" : "Eyes open spontaneously"
        }]
      }]
    }
  }],
  "extension" : [{
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
    "valueCode" : "fhir"
  }],
  "url" : "http://hl7.org/fhir/Questionnaire/gcs",
  "identifier" : [{
    "system" : "urn:ietf:rfc:3986",
    "value" : "urn:oid:2.16.840.1.113883.4.642.20.5"
  }],
  "name" : "GlasgowComaScore",
  "title" : "Glasgow Coma Score",
  "status" : "draft",
  "subjectType" : ["Patient"],
  "date" : "2015-08-03",
  "publisher" : "HL7 International / FHIR Infrastructure",
  "contact" : [{
    "telecom" : [{
      "system" : "url",
      "value" : "http://www.hl7.org/Special/committees/fiwg"
    }]
  }],
  "description" : "Glasgow Coma Score",
  "code" : [{
    "system" : "http://loinc.org",
    "code" : "9269-2"
  }],
  "item" : [{
    "linkId" : "1.1",
    "code" : [{
      "system" : "http://loinc.org",
      "code" : "9270-0"
    }],
    "type" : "coding",
    "answerValueSet" : "#verbal"
  },
  {
    "linkId" : "1.2",
    "code" : [{
      "system" : "http://loinc.org",
      "code" : "9268-4"
    }],
    "type" : "coding",
    "answerValueSet" : "#motor"
  },
  {
    "linkId" : "1.3",
    "code" : [{
      "system" : "http://loinc.org",
      "code" : "9267-6"
    }],
    "type" : "coding",
    "answerValueSet" : "#eye"
  }]
}